This overview of the emergency response cannot cover in detail what happened. It is instead focused on the standards required by JESIP and the Joint Doctrine to achieve an effective multi‑agency response, and where they were not met on 22nd May 2017.
There are a number of themes in the problems that arose in the emergency response. These are set out below and will be explored in the more detailed analysis of the emergency response that follows in Parts 13, 14 and 15.
First, there was the lack of communication between emergency responders, both through the act of physically co‑locating at a single multi‑agency RVP and via radio.
Second, there was the failure to have available either a multi‑agency control room talk group or to set one up on the night. This would have allowed control rooms to speak to each other directly.
Third, there was the failure by the FDO to inform other emergency services of his declaration of Operation Plato or to keep it under review.
Fourth, there was the failure by the FDO and others in GMP to consider zoning the scene, following the declaration of Operation Plato, in the early stages of the response.
Fifth, there was the failure to set up an FCP. This was principally the responsibility of GMP.
Sixth, there were delays by NWAS in getting ambulances and paramedics to the scene.
Seventh, there was the failure to send all HART operatives into the City Room to assist with triage and life‑saving intervention of casualties.
Eighth, there was the failure to send non‑specialist paramedics into the City Room to assist with triage.
Ninth, there was the failure to get stretchers to the City Room to help evacuate the injured.
Tenth, there was the failure by GMFRS to arrive on scene and make the contribution in removing the injured that its officers could have done.
Eleventh, there was the failure of NWFC to give important information to officers in GMFRS.
Twelfth, there was the failure of anyone in a senior position in GMFRS to take a grip of the situation during the critical period of the response.